What are the treatment options for tics?

Treatment Options for Tics

Behavioral therapies should be considered as first-line treatment for tics, followed by pharmacological options for more severe cases, and deep brain stimulation for severe treatment-refractory cases. 1, 2

First-Line Treatment: Behavioral Interventions

• Habit reversal training (HRT) and Comprehensive Behavioral Intervention for Tics (CBIT) have the strongest empirical support for treating tics 3, 2
• Exposure and response prevention (ERP) is also recommended as a first-line behavioral therapy 1, 4
• These behavioral interventions view tics as habitual responses that may be strengthened through negative reinforcement 2
• Internet-based and telehealth approaches to behavioral therapy can facilitate wider accessibility when in-person treatment is not available 2, 5

Pharmacological Treatment Options

For patients with more severe tics that significantly impact daily functioning:

• Alpha-2 adrenergic agonists (e.g., Clonidine) are recommended, especially when ADHD is comorbid 1, 6
• Anti-dopaminergic medications are effective for tic management 1:
  • Typical antipsychotics: Haloperidol, Pimozide
  • Atypical antipsychotics: Risperidone, Aripiprazole

Pimozide Dosing Guidelines

• For children: Start at 0.05 mg/kg at bedtime, may increase every third day to maximum 0.2 mg/kg (not exceeding 10 mg/day) 7
• For adults: Start with 1-2 mg/day in divided doses, may increase every other day, most patients maintained at less than 0.2 mg/kg/day or 10 mg/day 7
• Pimozide is indicated for suppression of motor and phonic tics in patients with Tourette's Disorder who have failed to respond to standard treatment 7
• Important: CYP2D6 genotyping should be performed at doses above 0.05 mg/kg/day in children and above 4 mg/day in adults 7

Treatment for Comorbid Conditions

• For tics with comorbid ADHD: Stimulants may be used with proper informed consent 8
  • Contrary to previous beliefs, recent studies show stimulants are effective for ADHD in patients with tic disorders and in most cases do not worsen tics 8
  • If tics worsen markedly on one stimulant, consider an alternative stimulant 8

Advanced Treatment Option: Deep Brain Stimulation (DBS)

For severe, treatment-refractory cases:

• DBS may be considered in patients who meet the following criteria 8:
  • Failed to respond to behavioral techniques and at least three medications proven efficacious for tics
  • Severe functional impairment due to tics
  • Stable and optimized treatment for comorbid conditions for at least six months
  • Generally recommended for patients above 20 years of age due to potential for spontaneous remission in younger patients 1

Treatment Algorithm

1. Mild to moderate tics: Start with behavioral interventions (CBIT, HRT, or ERP) 1, 3, 2
2. Moderate to severe tics with significant functional impairment:
   • Add pharmacological treatment with alpha-2 adrenergic agonists (especially with comorbid ADHD) 1, 6
   • If inadequate response, try anti-dopaminergic medications 1, 6
3. Severe, treatment-resistant tics in adults: Consider DBS evaluation 8
4. For tic cough specifically: Consider hypnosis, suggestion therapy, or combinations of reassurance and counseling 8

Important Clinical Considerations

• Avoid misdiagnosing tics as habit behaviors or psychogenic symptoms 1, 9
• Comprehensive assessment should include evaluation of common comorbidities like ADHD (present in 50-75%) and OCD (present in 30-60%) 1, 9
• Treatment should focus on tics that cause significant functional impairment rather than those that are merely cosmetically troublesome 7
• Regular attempts should be made to reduce medication dosage to see if tics persist at the previously identified level 7